Lifesaving Medications, Through a Back Door

Tuesday

A patient illicitly selling part of his medication helps fight AIDS in his own strange way.

One of my big headaches at the moment is a patient — call him Ralph — who appears to be one of the most successful small-time alchemists in all of New York.

He creates gold from dross modern-style, filling his prescriptions every month like clockwork and then selling the unopened bottles for hundreds of dollars each on a street corner somewhere. A Medicaid card financed at great expense by his fellow citizens should really not be used as a cash card, and shortly I plan to help dismantle his enterprise.

But sitting in a darkened auditorium the size of a football field in Vienna last week, one of the 20,000 attendees at the big biennial international AIDS conference, I began to think about Ralph in a new light.

It’s all about global access to lifesaving drugs these days, and things are looking up in a ‘been down so long’ sort of way. Against all odds, more than 5 million H.I.V. infected people worldwide are on treatment, a minority of those who need it, but still a creditable start. Whether the international funds that created this momentum will sustain it is another story, already competing health agendas are draining some of it away.

Knowing Ralph as I do, I can easily predict his reaction to this and all similar statistics from the rest of the world: he shrugs, he smiles. “What’s that got to do with me?”

In the past, I might have agreed with him. It can be remarkably difficult to make any solid mental and emotional connection between AIDS in wealthy countries and the roiling new infections of the third world. Here, it is all about fine tuning regimens, learning to cope with the drug side effects long term. There, it is all blood and triage, high-energy battlefield medicine. There, it is all about saving lives, and here we have Ralph, selling his life away.

Ralph — middle-aged, with a bald spot and a paunch — was born in New York and has lived here all his life. He worked at a blue-collar job in Midtown Manhattan until technology made his job obsolete. He has been a recreational drug user for decades and developed AIDS at least 15 years ago. The fact that he is still alive today is testament to the fact that some of the truisms about his disease are actually not uniformly true: it doesn’t kill everyone, at least not right away, even if they habitually play fast and loose with their meds.

As far as I can figure out, Ralph takes his pills for a few months out of the year. I got records from the last clinic he was asked to leave when his entrepreneurial tendencies became clear, and his blood tests are fascinating. Some months they look pretty good, other months they are terrible, with sky-high levels of virus and almost no immune cells.

I assume those are the months when his bottles of a particularly valuable combination AIDS pill — one of my other patients tells me each bottle will fetch many hundreds of dollars on the black market — move from Ralph’s possession to someone else’s.

I wish I knew more about the black market for prescription drugs in our country. It is one of the many germane items that have yet to make it into the continuing medical education curricula. Most of what I know comes from patients, with a few facts from the odd phone conversation with the Medicaid fraud unit. It seems that the exuberant market for narcotics and sedatives is mostly domestic — these pills have become the most abused drugs in the country, more than heroin, more than cocaine. Patients can sell them off a few at a time and make a few dollars.

But those sealed bottles of lifesaving AIDS medication that net thousands of dollars have another destination. They go out of the country, to eager markets in the Caribbean and elsewhere in the developing world. There the seals will be broken and the pills will be taken by desperate men and women who want to live. A reporter for Mother Jones painstakingly traced this modern trade route a few years ago, from the patients selling their pills along Ninth Avenue to a doctor in the Dominican Republic slipping patients a contact number to buy the drugs. “It is something I cannot fight,” the doctor said. “People want to live.”

At these international conferences many of the delegates are H.I.V. infected and, by definition, healthy, or at least well enough to travel. Periodically a presenter will show videos of the sick ones back at home: skeletal before the drugs arrive; weeping with joy and gratitude afterward.

And I think of Ralph: his luck, his profligacy, and the fact that in a way he is actually doing more for the international effort than I am. Or, in a strange way, helping me do my part.

Ralph is a tough nut to crack. He has been through many doctors — all ringing his death knell in ever more emphatic tones — and doesn’t pay much attention to the lectures any more. His health seems to be pretty good. He is a little overweight and his legs hurt, but he hasn’t been hospitalized in years. If my experience with patients like him over the years is any guide, he will change his modus operandi only when he does become as skeletal and desperately ill as the people in those videos.

Or, perhaps, his life will be saved in another way. When the world’s supply of lifesaving meds expands enough, the middleman on the corner will no longer interested be in Ralph’s small contribution. Then he will have to take those meds himself. Think of it, Mr. Gates and Mr. Clinton, all you folks at Pepfar and Unaids, all you big hearts and big pockets of the world: among the lives you save will be Ralph’s.

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